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Australasian Orthodontic Journal Volume 35 No. 1  May 201994 © Australian Society of Orthodontists Inc. 2019
Background: Micro-osteoperforation (MOP) is a newly developed technique reported to accelerate orthodontic tooth movement. 
Case presentation: The following case report discusses a peripheral ossifying fibroma (POF), as a reactive gingival nodule 
that developed eight weeks after a patient underwent transmucosal MOP at multiple sites in the mandible during orthodontic 
treatment. 
Conclusion: The MOP procedure is a relatively new approach applied to orthodontics that may induce gingival reactive nodules. 
Clinicians should be aware of this possible sequela and inform patients of the potential risk. 
(Aust Orthod J 2019; 35: 94-97)
Received for publication: August 2018
Accepted: January 2019
Development of peripheral ossifying fibroma 
following micro-osteoperforation 
Abdulmonem Alshihri,* Daliah Salem† and Mark A. Lerman+
King Saud University, College of Dentistry, Riyadh, SA,* Goldman School of Dental Medicine, Boston University, Boston, 
MA, USA† and Tufts University School of Dental Medicine, Boston, MA, USA+
Introduction 
Micro-osteoperforation (MOP) is a newly-developed 
procedure intended to accelerate the movement 
of teeth during orthodontic treatment. MOPs are 
performed under local anesthesia without reflecting 
mucoperiosteal flaps. Manual drivers are used to 
penetrate through the oral mucosa and the cortical 
bone. The generated holes extend for a few millimeters, 
passing through the buccal cortex and proximal to the 
root in the area being targeted. 
MOP of the alveolar bone has been shown to induce 
osteogenic inflammatory markers during orthodontic 
movement.1,2 Tooth movement and bone resorption 
is a cycle that is associated with reactive osteoclastic/
osteoblastic activities in the PDL and periosteum. 
Inflammatory markers such as chemokines and 
cytokines are up-regulated in response to conventional 
orthodontic forces. Furthermore, gingival crevicular 
fluid sampling has measured a significantly 
increased inflammatory stimulation after micro-
osteoperforations have been performed.1,3,4  
A peripheral ossifying fibroma (POF) is a common 
benign reactive gingival nodule with a slight female 
predilection and incidence rates reported to vary 
between different ethnic populations.5,6 
POFs are believed to result from gingival injury and/
or chronic irritation of the periosteal and periodontal 
cells.7-9 To the best of current knowledge, POFs have 
yet to be reported developing in possible association 
with stimulation via MOP.
Case report
A 29-year-old male undergoing orthodontic treatment 
developed an asymptomatic mandibular gingival 
mass and was referred to a private practice in Boston, 
MA for periodontal evaluation. On examination, 
the patient reported that the lesion had developed 
over a period of four weeks. Two months prior to 
that, he underwent MOP (PROPEL Orthodontics 
– Ossining, NY, USA) as a part of his orthodontic 
treatment plan (Invisalign, CA, USA). The MOP was 
performed at several sites in the mouth, including 
between the maxillary (bilaterally) and mandibular 
(left) first and second premolars and between all of the 
second premolars and first molars. The patient was 
instructed not to use non-steroidal anti-inflammatory 
Abdulmonem Alshihri: monem.alshihri@post.harvard.edu;  Daliah Salem: dms53@bu.edu;  Mark A. Lerman: Mark.Lerman@post.harvard.edu
Australasian Orthodontic Journal Volume 35 No. 1  May 2019 95
REACTIVE LESIONS FOLLOWING MICRO-OSTEOPERFORATION
drugs (NSAIDs) during treatment to avoid reducing 
the amount of inflammation, which could inhibit 
orthodontic movement.
An intraoral assessment identified a well-circumscribed 
firm mass located on the buccal gingiva of the 
mandibular left posterior dentition, between the first 
and second molars. It was painless, pink-red in color, 
measured 8 mm in diameter and therefore spanned 
the width of the interdental papilla (Figure 1A). The 
buccal aspects of the first and second molars had 
attachments for the sequential aligners the patient was 
wearing as part of the clear aligner treatment. 
The patient maintained good oral hygiene with no 
history of trauma or other dental or medical concerns. 
There were no deep probing depths or periodontal at-
tachment loss. Endodontic vitality tests were within 
normal limits and a bite-wing radiographic evaluation 
was unremarkable (Figure 1B). An extra-oral exami-
nation was negative with no palpable submandibular/
cervical lymphoadenophathy or muscular involve-
ment.
Based on the history and clinical findings, differential 
diagnoses of a pyogenic granuloma (PG), a peripheral 
giant cell granuloma (PGCG), or a peripheral 
ossifying fibroma (POF) were considered. The 
patient consented to an excisional biopsy and related 
treatments. The excised specimen was preserved in 
10% formalin and sent for histopathologic processing 
and examination, which revealed a nodule surfaced 
by focally ulcerated stratified squamous epithelium 
exhibiting mild acanthosis (Figure 2A). Within the 
subjacent fibrous connective tissue, there was an 
unencapsulated proliferation of fibroblastic spindle 
cells producing variably calcified osteoid material 
and interconnecting trabeculae of bone (Figure 
2B). Extravasated erythrocytes and dilated vascular 
Figure 1a. Well-circumscribed firm mass 
at the interdental papilla between the first 
and second mandibular molars.
Figure 1b. Bite-wing radiograph of the area showing normal radiographic 
findings.
Figure 2a. Nodule surfaced by parakeratinized epithelium (hematoxylin 
and eosin, magnification × 20).
Figure 2b. Spindle cells, mineralised tissue, and dilated vascular 
channels (haematoxylin and eosin, magnification × 200).
Australasian Orthodontic Journal Volume 35 No. 1  May 201996
ALSHIHRI, SALEM AND LERMAN
channels were also present. These findings were 
consistent with a diagnosis of POF. At four months 
follow-up, there was no clinical evidence of recurrence 
(Figure 3).
protein expressed in various cells, tissues, and 
physiological processes that play a critical role in 
inflammatory disorders. Furthermore, numerous 
studies have shown that OPN is expressed in 
inflammation by macrophages and is also activated 
at sites of ectopic pathologic calcification.7,13,14 It is 
possible that inflammation associated with MOP 
induced the development of the POF described in the 
present study. 
The development of the POF occurred proximal to 
a site of MOP trauma. It is difficult to discern why 
the lesion occurred at that specific location. However, 
it may be speculated that the POF was attributed to 
the amount/type of pressure exerted by the buccal 
attachments on the first and second molars while 
the aligners were worn. The amount of movement 
generated at that site, and the presence of plaque 
that may have accumulated during healing may be 
additional contributing factors. 
Conclusion 
This is the first reported case of a POF arising in a 
patient having experienced transmucosal/gingival 
MOP. As the procedure is relatively new, further 
prospective studies are needed to evaluate the potential 
association between MOP and the formation of 
reactive gingival nodules including POFs. Clinicians 
should be aware of the possible development of these 
lesions and the iatrogenic factors that may play a role.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
The authors would like to thank the College of 
Dentistry Research Center and the Deanship of 
Scientific Research at King Saud University, Riyadh, 
Saudi Arabia, for their support to report this case.
Corresponding author
Abdulmonem Alshihri
College of Dentistry
King Saud University
Riyadh 11545
Kingdom of Saudi Arabia
Email: monem.alshihri@post.harvard.edu 
Discussion 
POF is noted as a common reactive nodule of the 
gingiva. Clinically, the differential diagnosis for POFs 
also includes other tumour-like hyperplastic growths 
such as fibromas, PGs, and PGCGs.5,6,10 Any of these 
reactive lesions may present as sessile or pedunculated 
growths of variable size. Most develop in response to 
local irritants or chronic low-grade trauma and rarely 
present with radiographic findings.5,6,11  
MOP is a traumatic procedure that could synergise 
with the inflammatory process of tooth movement. 
The up-regulation of inflammatory chemokines and 
cytokines has been demonstrated in association with 
tooth orthodontic-movement.3,4 Previous studies have 
shown that performing alveolar bone osteoperforation 
(decortication) can increase the expression level 
of inflammatory markers in a process intended to 
accelerate tooth movement by increasing osteoclastic 
activity.1,2,7 A recent prospective controlled clinical 
trial investigated the effect of MOP on root resorption 
during orthodontic treatment. The split mouth study 
showed that the teeth (premolars) that received MOP 
had approximately 42% more root resorption than 
the contralateral side after 28 days of treatment.12 
It was reflected upon as the result of an amplified 
inflammatory process that led to a significantly greater 
resorptive effect.12  
Upon immunohistochemical examination, reactive 
gingival nodules including POF have been shown to 
express osteopontin (OPN).7,13 OPN is a matricellular 
Figure 3. Biopsy site at four months follow-up. Healing at the site of 
concern seemed to occur uneventfully.
Australasian Orthodontic Journal Volume 35 No. 1  May 2019 97
REACTIVE LESIONS FOLLOWING MICRO-OSTEOPERFORATION
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Development of peripheral ossifying fibroma following micro-osteoperforation

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